Health information management (HIM) is the practice of ...



|Healthcare |

|To accompany the Healthcare Curriculum. |

|CTAE Resource Network, Instructional Resources Office, 2010 |

|Georgia Performance Standards: |

|HS-AHI-2. Students will analyze the role of health information management in healthcare organizations. |

|HS-AHI-3. Students will analyze career opportunities within the Health Informatics pathway. |

|See the end of this document for complete GPS listing |

Student Information Guide

Directions:

Use the information in this student information sheet to complete the accompanying student study sheet. Complete all items on the study sheet and turn in to the teacher.

[pic] Health Information Management (HIM)

What is Health Information Management?

Health information management (HIM) is the practice of maintenance and care of health records by traditional and electronic means in hospitals, physician's office clinics, health departments, health insurance companies, and other facilities that provide health care or maintenance of health records. Health informatics and health information technology are utilized in information management.

Health information management professionals have been described as playing a critical role in the delivery of healthcare in the United States through their focus on the collection, maintenance and use of quality data to support the information-intensive and information-reliant healthcare system. They work with clinical, epidemiological, demographic, financial, reference, and coded healthcare data. Health information administrators plan information systems, develop health policy, and identify current and future information needs. In addition, they apply the science of informatics to the collection, storage, use, and transmission of information.

HIM standards began with establishment of AHIMA

Health information management's standards history is dated back to the introduction of the American Health Information Management Association (AHIMA), founded in 1928 when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'

In 1938, AHIMA was known as American Association of Medical Record Librarians (AAMRL) and its members were known as medical record experts or librarians who studied medical record science. The goal of this career was to raise the standards of keeping records in hospitals and other healthcare facilities. The individuals involved in this profession were promoters for the successful management of clinical records to guarantee their precision.

Over time, the name AHIMA had changed to reflect the evolving field of health information management practices, eventually becoming the American Health Information Management Association. The association's current name is meant to cover the wide variety of areas health professionals work in today.

AHIMA members affect the quality of patient information and patient care at every touch point in the healthcare delivery cycle. They often serve in bridge roles, connecting clinical, operational, and administrative functions.

Health Information Management has changed with the changing healthcare industry, but the main goal is still to analyze, manage, and utilize the information that is essential to patient care and making sure the providers can access the information when necessary.

HIMSS establishment in 1961 increased industry knowledge

The Healthcare Information and Management Systems Society (HIMMS) was organized in 1961 as the Hospital Management Systems Society (HMSS), an independent, unincorporated, nonprofit, voluntary association of individuals. It was preceded by increasing amounts of management engineering activity in healthcare during the 1950s, when teachings by Frederick Winslow Taylor and Frank Bunker Gilbreth, Sr. began to attract the attention of health leaders.

The HIMMS grew to include chapters, membership categories, publications, conventions, and continues to grow in different parts of the world via its Europe, Asia Pacific, and Middle Eastern branches.

Modern development in health information management

The electronic health record has been continually expressed as an evolvement of health record-keeping. Because it is electronic, this means of recordkeeping has been both supported and debated in the health professional community and within the public realm.

89% of those who responded to a recent Wall Street Journal poll described themselves as "Very/Somewhat Confident" in their health care provider who used electronic health records compared to 71% of respondents who responded positively about their providers who didn't or don't use electronic health records. As of 2008, more than fifty-percent of Chief Information Officers polled listed that they wanted ambulatory electronic health records in order to have the health information record available to move across each stage of health care.

Health information managers are charged with the protection of patient privacy and are responsible for training their employees in the proper handling and usage of the confidential information entrusted to them. With the rise of technology's importance in healthcare, health information managers must remain competent with the use of information databases that generate crucial reports for administrators and physicians.

Professional organizations

• American Society of Health Informatics Managers (ASHIM)

• American Health Information Management Association (AHIMA)

• Commission on Accreditation of Health Informatics and Information Management Education (CAHIIM)

• Healthcare Information Management and Systems Society (HIMMS)

Records and practices used in health information management

Healthcare quality and safety require that the right information be available at the right time to support patient care and health system management decisions. Gaining consensus on essential data content and documentation standards is a necessary prerequisite for high-quality data in the interconnected healthcare system of the future. Continuous quality management of data standards and content is key to ensuring that information is usable and actionable.

Records

• The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases. This repository of information about a single patient is generated by health care professionals as a direct result of interaction with a patient or with individuals who have personal knowledge of the patient.

• The primary patient record is the record that is used by health care professionals while providing patient care services to review patient data or document their own observations, actions, or instructions.

• The secondary patient record is a record that is derived from the primary record and contains selected data elements to aid non clinical persons in supporting, evaluating and advancing patient care. Patient care support refers to administration, regulation, and payment functions.

Methods to ensure Data Quality

The accuracy of and proper data entry into computer systems depends on the manual or computer information system design for collecting, recording, storing, processing, accessing and displaying data as well as the ability and follow- through of the people involved in each phase of these activities. Everyone involved with documenting or using health information is responsible for its quality. According to AHIMA’s Data Quality Management Model, there are four key processes for data:

1. Application: the purpose for which the data are collected.

2. Collection: the processes by which data elements are accumulated.

3. Warehousing: the processes and systems used to store and maintain data and data journals.

4. Analysis: the process of translating data into information utilized for an application.

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Each aspect is analyzed with 10 different data characteristics:

1. Accuracy: Data are the correct values and are valid.

2. Accessibility: Data items should be easily obtainable and legal to collect.

3. Comprehensiveness: All required data items are included. Ensure that the entire scope of the data is collected and document intentional limitations.

4. Consistency: The value of the data should be reliable and the same across applications.

5. Currency: The data should be up to date. A datum value is up to date if it is current for a specific point in time. It is outdate if it was current at some preceding time yet incorrect at a later time.

6. Definition: Clear definitions should be provided so that current and future data users will know what the data mean. Each data element should have clear meaning and acceptable values.

7. Granularity: The attributes and values of data should be defined at the correct level of detail.

8. Precision: Data values should be just large enough to support the application or process.

9. Relevancy: The data are meaningful to the performance of the process or application for which they are collected.

10. Timeliness: Timeliness is determined by how the data are being used and their context.

[pic] Health Information Management as a Career

Accredited educational program development

The Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) defines standards which higher education health information management and technology programs must meet to qualify for accreditation. Students who graduate from an accredited associate's, bachelor's or certificate program are qualified to sit for their respective exams for certification as a Registered Health Information Technician (RHIT) - via graduation from an accredited associate or certification program - or Registered Health Information Administrator (RHIA), which requires education through an accredited bachelor or certification program.

Competency requirements are maintained by CAHIIM in their Associate Degree Entry-Level Competencies and Baccalaureate Degree Entry-Level Competencies definitions.

Further education for health information professionals

Education is an important aspect in being successful in the world of health information management. Aside from the initial credentials of RHIA or RHIT, health information professionals may wish to pursue a Masters of Business Administration, Masters of Health Administration, or other Masters programs in health data management, information technology and systems, and organization and management. Gaining further education advances the health professional's career and qualifies the individual for upper-management positions.

Health information professionals

HIM is a very broad and successful field for health care professionals. There are several career opportunities in Health Information Management upon completion of an accredited program. Medical records and health information technicians are described as having the following duties according to the Bureau of Labor Statistics' Occupational Outlook Handbook:

Assemble patients' health information including medical history, symptoms, examination results, diagnostic tests, treatment methods, and all other healthcare provider services. Technicians organize and manage health information data by ensuring its quality, accuracy, accessibility, and security. They regularly communicate with physicians and other healthcare professionals to clarify diagnoses or to obtain additional information.

In 2008, about 39 percent of health information technician jobs were in hospitals. While RHITs usually work in hospitals, they also work in a variety of other healthcare settings. There are traditional and non-traditional settings for an HIM professional to work within.

• Traditional settings include: Managing an HIM medical records department, physician offices, nursing homes, home health agencies, mental health facilities, outpatient care centers, public helath agencies,cancer registry, coding, trauma registry, transcription, quality improvement, release of information, patient admissions, compliance auditor, physician accreditation, utilization review, and risk management.

• Non-traditional settings include: consulting firms, government agencies, law firms, insurance companies, correctional facilities, extended care facilities, pharmaceutical research, information technology and medical software companies.

The increasing use of electronic health records (EHRs) will continue to broaden and alter the job responsibilities of health information technicians. For example, with the use of EHRs, technicians must be familiar with EHR computer software, maintaining EHR security, and analyzing electronic data to improve healthcare information. Health information technicians use EHR software to maintain data on patient safety, patterns of disease, and disease treatment and outcome. Technicians also may assist with improving EHR software usability and may contribute to the development and maintenance of health information networks.

Medical records and health information technicians' duties vary with the size of the facility where they work. Technicians can specialize in many aspects of health information. Some medical records and health information technicians specialize in codifying patients' medical information for reimbursement purposes. Technicians who specialize in coding are called medical coders or coding specialists. Medical coders assign a code to each diagnosis and procedure by using classification systems software. The classification system determines the amount for which healthcare providers will be reimbursed if the patient is covered by Medicare, Medicaid, or other insurance programs using the system. Coders may use several coding systems, such as those required for ambulatory settings, physician offices, or long-term care.

Medical records and health information technicians also may specialize in cancer registry. Cancer (or tumor) registrars maintain facility, regional, and national databases of cancer patients. Registrars review patient records and pathology reports, and assign codes for the diagnosis and treatment of different cancers and selected benign tumors. Registrars conduct annual follow-ups to track treatment, survival, and recovery. This information is used to calculate survivor rates and success rates of various types of treatment, to locate geographic areas with high incidences of certain cancers, and to identify potential participants for clinical drug trials.

Health information managers

Professional health information managers manage and construct health information programs to guarantee they accommodate medical, legal, and ethical standards. They play a crucial role in the maintenance, collection, and analyzing of data that is received by doctors, nurses, and other healthcare players. In return these healthcare data contributors rely on the information to deliver quality healthcare. Managers must work with a group of information technicians to guarantee that the patient's medical records are accurate and are available when needed.

Health information managers are typically certified as a Registered Health Information Administrator (RHIA) after achieving a bachelor's degree in health informatics or health information management from a school accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) and after passing their respective certification exam.

The Certified Health Informatics Systems Professional (CHISP) certification offered by American Society of Health Informatics Managers (ASHIM) is to credit an IT professional who is able to support physician adoption of Health IT. A CHISP professional needs to process knowledge of the health care environment, Health IT, IT, and soft skills including communication skills.

RHIAs usually assume a managerial position that interacts will all levels of an organization that use patient data in decision making and everyday operations. They may work in a broad range of settings that span the continuum of healthcare including office based physician practices, nursing homes, home health agencies, mental health facilities, and public health agencies.

Health information managers may specialize in registry management, data management, and data quality among other areas.

Future Direction for Health Information Management

HIM professionals have an the opportuntiy to choose from a variety of healthcare work environments. If you have an interest in working in a health-related occupation, but not directly with patients, this may be a good field to consider working in. The growth of this job market is expected to grow much faster than average, particularly for technicians with a strong understanding of technology and computer software.

According to the U.S. Bureau of Labor Statistics, Employment of medical records and health information technicians is expected to increase by 20 percent, much faster than the average for all occupations through 2018. Employment growth will result from the increase in the number of medical tests, treatments, and procedures that will be performed. As the population continues to age, the occurrence of health-related problems will increase. Cancer registrars should experience job growth as the incidence of cancer increases from an aging population.

In addition, with the increasing use of electronic health records, more HIM professionals will be needed to complete the new responsibilities associated with electronic data management. As this field grows and information technology becomes a more crucial part of the medical world, health information management is experiencing a transition from traditional managing practices with paper to more efficient electronic management with electronic health records.

[pic] Georgia Performance Standards

HS-AHI-2. Students will analyze the role of health information management in healthcare organizations.

a. Research the history of health information technology and trends in the management of health records.

b. Explain the role of the health information management department in the healthcare organizations.

c. Describe the variations in definitions of health information management.HS-AHI-2. Students will analyze the role of health information management in healthcare organizations.

HS-AHI-3. Students will analyze career opportunities within the Health Informatics pathway.

d. Describe the role of the health information manager/supervisor.

e. Identify the credentialing processes necessary for health informatics careers to include licensure and certification.

[pic] License & Verification

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